MEDICARE: DAVID RANDOLPH WASSERMAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	693	NV

General Provider Information

NPI Number	:	1902971005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID RANDOLPH WASSERMAN DMD

Provider Business Mailing Address
First Line	:	4055 SO SPENCER STREET
Second Line	:	SUITE 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5251
Country	:	US
Telephone Number	:	702-734-2711
Fax Number	:	702-734-9417

Provider Business Practice Location Address
First Line	:	4055 SO SPENCER STREET
Second Line	:	SUITE 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5251
Country	:	US
Telephone Number	:	702-734-2711
Fax Number	:	702-734-9417

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/08/2007

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